MEDICARE: RALEIGH OT LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	225XE1200X	Ergonomics Occupational Therapist
2	225XG0600X	Gerontology Occupational Therapist
3	225XP0200X	Pediatric Occupational Therapist
4	225X00000X	Occupational Therapist

General Provider Information

NPI Number	:	1538052410
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RALEIGH OT LLC

Provider Business Mailing Address
First Line	:	4912 SWEET SHADE TRL
Second Line	:
City	:	RALEIGH
State	:	NC
Zip	:	27616-4652
Country	:	US
Telephone Number	:	801-739-3787
Fax Number	:

Provider Business Practice Location Address
First Line	:	4912 SWEET SHADE TRL
Second Line	:
City	:	RALEIGH
State	:	NC
Zip	:	27616-4652
Country	:	US
Telephone Number	:	801-739-3787
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	JACOB HAWKINS
Credential	:
Telephone Number	:	801-739-3787

Provider Enumeration Date	:	05/30/2025
Last Update Date	:	05/30/2025

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